Selecting a Nursing Home
The thought of nursing home placement is one that strikes fear for many older adults and their families. Although this decision is never easy, this guide intends to provide you with information to help make the choice of which facility as well as make the transition a little easier.
The stigma associated with nursing is still alive and well. In the past, many were institutional settings with wards of residents. The rumors of poor care, poor conditions and overall neglect were rampant. Many felt they were “dumped” into the facility because no one else was willing to care for them. Others simply didn’t have any one to care for them.
Beating the reputation of facilities of the past has proved to be difficult. Many of today’s elderly remember these institutions and do not want to subject themselves or their loved one to such conditions. However, it is important to note, that today’s regulations are much more stringent and although there are instances of neglect, abuse and poor care, these are the exception and not the norm. The Department of Health conducts yearly surveys or inspections to ensure that residents are safe, cared for and living with the dignity they so much deserve. The surveyors take notice of everything from cracks in the wall to staffing levels to the number and cause of bed sores. Each state’s Department of Health can also be notified when a family or patient suspects any wrong doing on the part of the facility.
The term nursing home is actually an outdated term. Most industry professionals have tried to eliminate the usage of the phrases like nursing home or convalescent home, which conjure negative images. Skilled nursing facility or post-acute rehab facility are now more accepted in the health care community.
There are several key players in a skilled nursing facility. A federally licensed administrator oversees the day to day operations of the facility while a director of nursing oversees the clinical team. A medical director is also responsible for making sure that quality assurance is met on the clinical level. Attending physicians are given rights to follow their patient’s care while at the facility, while specialists such as psychiatrists and podiatrists are often referred to for interdisciplinary care.
Another integral department within a skilled nursing facility is social services. The social service team ensures the well being of the residents and helps determine appropriate discharge plans. They are often the problem-solvers of the facility and are often the first-line of defense for any problems that arise.
The rehabilitation team is vital for helping patients maintain their highest level of functionality. Most facilities will offer physical, occupation and speech therapies. Some will also have certified recreational therapists available.
In most facilities, there is also an admissions or intake coordinator who helps the transition from the hospital or home to the facility. This person generally works closely with outside agencies and families to ensure criteria is met for nursing home placement and can offer tours and information regarding the building’s services.
Most of today’s skilled nursing facilities provide various levels of care, from short-term rehab to long-term care.
Those needing long-term care generally need 24-hour nursing supervision and assistance with most or all of their activities of daily living (ADL). For many families this is a last-resort option. In some cases, the resident has tried to remain as independent for as long as possible by utilizing care givers and in some instances by residing in an assisted living facility or personal care home. The transfer to a skilled nursing facility is usually a permanent placement and the facility becomes home.
When you have made the decision to place your loved one in a skilled nursing facility for long-term care, there are several deciding factors that you should consider when selecting a facility.
1. Home Like Environment
The best way to assess a facility is to take a personal tour. Most facilities will encourage you to tour in order to help dispel any of the preconceived notions that may be had regarding skilled nursing homes. When touring keep notice for:
- How are the residents clothed? Pay close attention to how the patients are dressed. Are they still in their pajamas late in the day or are they properly dressed? Residents, unless, should be encouraged to be dressed on a daily basis.
- Do you notice any odors? Most facilities today are vigilant in keeping the facility odor free. There are always going to times of the day when odors are more prevalent like during morning dressing times, but otherwise they should be isolated and controlled quickly.
- Are the hallways clean and free of clutter?
- Are the rooms clean and free of clutter?
- Are the rooms decorated with personal belonging or are they barren and hospital-like?
- Does the staff address the residents respectfully?
- What types of bedrooms do they have available: private, semi-private, triples or quad occupancy?
- Are there areas for the family to gather for visits or special occasions?
2. Nursing Capabilities
Since many of the patients residing in long-term care settings require more intense nursing care; here are some questions to consider when deciding on a facility:
- Does the facility provide 24-hour RN coverage? Even though it is federally mandated that all facilities have 24-hour LPN coverage, there are some duties that only and RN is qualified to do, such as IV administration. .
- Are the nursing assistants certified?
- Can the nursing staff handle advanced care needs such as wound therapy?
- Can the nursing staff handle the needs of patients with dementia?
- Does the facility use contract agencies?
- Does it appear as if the nursing staff is enjoying their work and that morale is high throughout the building?
- Does each patient have individualized plans of care?
3. Dining Services
Dining is not only an opportunity for patients to eat, but it is also a time for socialization and camaraderie. Some important considerations when choosing a facility include?
- What type of dining program is offered? Some facilities offer restaurant like dining, while others serve all residents the same meal with limited opportunity for alternatives.
- Are residents encouraged to eat in the dining room?
- Are residents who are unable to feed themselves assisted by facility staff?
- Are special dietary needs able to be met?
- How is the food? Ask for a sample menu or sample meal so that you can see if you approve Keep in mind, however, many facilities will limit the amount of salt and seasonings to accommodate diet specific restrictions.
For residents in a nursing home, planned activities are vital to the long-term care setting. They provide opportunity for socialization as well as cognitive stimulation. Some questions to consider:
- Are there activities my loved one would enjoy?
- Is there diversity amongst the activities?
- Are their activities that they can do in independently?
- Are there activities that will get them outside?
- Are there activities that will take them off premises?
- Do the residents participate and enjoy the planned activities?
For many, the need for nursing home placement is only temporary. After surgery or a lengthy illness, many people need a place to recuperate where they can receive specialized nursing care and rehabilitation. Many skilled nursing facilities now offer short-term stay opportunities to help patients get the care they need to get back to their prior level of living. Many patients utilizing short-term rehabilitation are not “typical” nursing home patients; many are younger, are more independent and are generally in better health.
While the same criteria should be used when choosing a facility for post-acute care as for long-term care, there are some additional factors to be considered. They include:
Physical, occupation and speech therapy play an integral role in the recovery after an illness or surgery. Some patients may need the services of all three disciplines, while others may only need one or two. Most patients will need occupational and physical therapy and will be required by most insurance companies to receive therapy five days per week. Some questions to consider when choosing a facility include:
- Is the therapy team contract or employed by the facility?
- Does the therapy team consist of certified therapists?
- Are there any special credentials of the therapists?
- Is there any advanced techniques that the therapists use to aid in their
- Will the therapists evaluate the home environment prior to discharge?
- Will the therapists help educate caregivers on therapy techniques prior to discharge?
- Is there a track record of successful rehabilitation?
Be sure that there are activities that align with the needs of your loved one. Non-traditional nursing home residents may not want to participate in activities geared towards long-term residents like Bingo or bean bag toss. It is important, however for them to be able to socialize and take their mind of the fact that they are not at home.
3. Pre-Surgery Registration
If you know that surgery is in the future and are uncertain as to the reality of recuperating at home, speak with the doctor to see if a post-acute rehab stay would be a foreseeable option. Many facilities now offer the option of pre-registering for your short-term stay. For example, if you or your loved one is scheduled for a hip replacement, and knowing that you have a flight of stairs to climb to get to the bathroom, it may be wise to consider a short-term rehab stay. You then, can tour the facilities, ask the appropriate questions, meet the appropriate staff who will be caring for you and make an informed decision on where you would like to recuperate. In addition, many facilities will allow you to do the admissions paperwork in advance, making the transition from the hospital to the facility.
When the clinical team, therapy team and social service team have decided that it’s time for discharge, plans are made to ensure the safest return to home. In some cases, referrals are made for continued therapy, home health services or non-medical
While the initial goal upon admission for many is to return to their prior level of living, reality is sometimes different. For some, their disease state, advanced age or social situation plays against them. For those individuals, discharge to the safest environment is paramount. Some may be able to go to a lesser-level of living such as a personal care home or assisted living, while others may be finding the facility has become their permanent residence.
The facilities social service department can help determine and plan of action for appropriate discharge.
With over 5 million American’s suffering from Alzheimer’s and dementia-like diseases, the task of caring for them often lands on the shoulders of a loved one. While for some, at-home care is all that is needed, others require 24/7 supervision for many reasons, including personal safety. Some dementia patients are not oriented to time, place or person and simply do not know how to care for themselves any more. When the task for caring for a loved one with dementia becomes to much for a family to handle, alternative placement options must be considered. Many skilled nursing facilities do offer specialized dementia units with staff trained in caring for adults with the disease. If you are looking to place your loved one in a nursing facility because of cognitive impairments, here are some questions to consider?
- Some questions to consider when looking for dementia care at a skilled nursing facility:
- Does the facility have a secured unit to prevent the resident from eloping?
- Does the facility offer other types of devices to prevent the resident from leaving the building?
- Does the facility offer programming designed specifically for residents with dementia?
- If the facility has a specific dementia unit, does it have a dedicated staff?
For many families making this decision, it is often harder on them then it is on the resident. This is normal and should be expected. It is often more difficult to accept the fact that a physically “healthy” individual is no longer able to care for themselves due to cognitive impairment.
Learn more about Dementia, Alzheimer’s and memory care in the following resources:
- The Caregivers Guide to Alzheimer’s Disease: 20 Memory Care Experts on Caring for Alzhiemer’s and Dementia Patients
- Complete Guide to Memory Care
For many caregivers, the opportunity to go on vacation or take a break from caring for a loved one is very limited. Many facilities will offer to respite care for short durations to allow such a reprieve. This is a nice way to get a “taste” of what the facility has to offer without permanent placement. Unfortunately, most respite stays are not covered by insurance and will require private pay. Learn more about respite care in our Respite Care 101 Guide.
Nursing Homes vs. Skilled Nursing Facilities
The terms “nursing home” and “skilled nursing facility” are often used interchangeably, but the two actually differ. Skilled nursing facilities are sometimes part of larger nursing homes or even part of an acute care facility (hospital). The term skilled nursing refers to the level of medical care required by patients. Skilled care includes physical, occupational and speech therapies or skilled nursing services such as intravenous therapy.
Skilled nursing staff consists of the following professionals:
- Registered nurses (RNs) and licensed practical nurses (LPNs)
- Physical and occupational therapists
- Speech-language pathologists
Skilled nursing care can be understood as care that must be provided by a skilled or licensed professional, and it must be certified as medically necessary by a licensed physician. Medicare certifies skilled nursing facilities if they have the staff and equipment needed to provide this type of skilled care. But skilled care is typically only provided for a short time following a three-day qualifying hospital stay (not counting the day of discharge) and for one of the following reasons:
- To maintain a patient’s current functional status and prevent a condition from getting worse.
- To help improve a patient’s condition over a specified period of time.
The goal of skilled nursing care is to help an individual learn to live more independently and take care of their own personal care needs. The individual must continue to benefit from the skilled services being provided in order to maintain Medicare or private insurance coverage for those services.
If an individual’s condition cannot be improved or maintained through skilled nursing care, or the condition ceases to improve despite the treatments provided, the person typically only qualifies for custodial care. In contrast to skilled nursing care, custodial care is often needed for much longer periods of time, months or even years.
Custodial care is the care offered by a nursing home. The confusion between the two terms is due to the fact that skilled nursing care and custodial care are often provided within the same facility. But a nursing home stay won’t be covered by Medicare if the resident requires only custodial care, or care which can safely and reasonably be provided by staff who are not skilled or licensed professionals.
This type of care includes non-skilled services and assistance with activities of daily living (ADLs), such as bathing and dressing. Custodial care can also include oxygen or caring for a colostomy or bladder catheter, or other tasks that most people are able to do for themselves, such as diabetes monitoring. Skilled nursing facility care is generally considered short-term care, while the custodial care offered by nursing homes is considered long-term care.
Skilled nursing care is the most expensive level of care available. The national average is around $224 per day, but this varies depending on location as well as services needed.
There are several ways to help cover the cost of nursing home care.
- Medicare: For some patients, Medicare A can help with the cost of nursing home placement. For those who are eligible, Medicare can help pay for up to 100 days per calendar year. However, there are several criteria which need to be met for Medicare A to pay. The patient must have a 3 midnight admission to a hospital and require skilled services (i.e.: intensive nursing services, 5-day a week therapy needs, etc.). There are opportunities for long-term patients to regenerate their Medicare A benefits if they are rehospitalized for three days. Medicare part B can also help pay for in-patient rehabilitation services for long-term residents. For more information on what Medicare covers in a nursing home, contact www.medicare.gov.
- Medicaid: If a patient qualifies, Medicaid can help cover the cost of skilled nursing care. Depending on a person’s assets and income, Medicaid can be used to cover the Medicare co-pays or for their long-term care. For more information on
- Medicare Replacement Plans: Some insurance companies provide Medicare replacement plans, which as the name implies, replaces a person’s federal Medicare benefits. Plans such as Humana and Aetna, among countless others, provide the patients with primary insurance coverage. Each plan has differing benefits, but most offer some sort of skilled nursing coverage.
- Medicare Supplemental Plans: These plans are used in addition to Medicare and will often help cover any co-pays that may incur from Medicare. Each plan is unique and benefits should be verified before assuming coverage.
- Long-term Care Insurance: There are many companies providing long-term care insurance. These insurance policies may help cover nursing home care, but because each company has varying levels of coverage it is best to read the policy carefully and speak with a representative about coverage.
- Private Pay: For those who do not qualify for Medicaid or do not have supplemental insurance with skilled nursing benefits, costs that are incurred in a skilled nursing facility, including co-pays, room and board, medications, specialized care and rehabilitation are billed to the individual. It is recommended to seek out the advice of an elder law attorney if there are any substantial assets including cash, stock, bonds and real estate.
The reality is most people are hesitant about choosing a senior citizen housing option, like a skilled nursing facility, for a loved one, but there are times when the option of caring for them at home or allowing them to remain independent is just not in their best interest. Skilled nursing facilities can offer a wide range of services to meet the needs of many older, and some younger adults, but the process is often overwhelming. This guide is designed to make that process a little easier.
Nursing Homes are Closing at a Rapid Rate! [Infographic]
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